eMedicine Specialties > Plastic Surgery > Eyelids

Blepharoplasty, Lower Lid Transconjunctival

Christian N Kirman, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center
Gaurav Bharti, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center; Joseph A Molnar, MD, PhD, FACS, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine

Updated: Oct 27, 2009

Introduction

Initially titled in 1818 by Graefe, blepharoplasty is currently one of the most commonly performed aesthetic procedures but is still regarded as a technically challenging operation that requires thorough understanding of anatomy and function of the eyelids.¹

As the lower eyelid ages, excess skin, muscle, and fat cause an unattractive bulge to develop below the eye. The orbital septum becomes lax with aging, and this can lead to bulging of the orbital fat through the weak septum. Traditionally, these problems have been addressed by a transcutaneous blepharoplasty, where an incision is made through the skin to resect excessive orbital fat, redundant muscle, and skin if needed. The transconjunctival blepharoplasty is receiving increasing attention as an alternate technique to traditional transcutaneous blepharoplasty. With the transconjunctival technique, an incision is made through the lower lid conjunctiva, thereby avoiding an external incision through the skin and leaving no obvious scar. Many of the lower lid malpositions appear to be obviated by the use of this technique.^2,3

Potential complications that may occur after a classic transcutaneous blepharoplasty have been well described, including a postoperative change in the shape of the aperture, inferior scleral show, and malposition of the lower eyelid. Transconjunctival blepharoplasty has been advocated to limit the incidence of these complications, particularly in patients with minimal skin and muscle laxity or predominant fat herniation who otherwise would not require skin excision.⁴

As the transconjunctival technique of lower lid blepharoplasty is more widely used and reported, experience suggests that the transconjunctival approach is a safe and effective procedure with minimal complications. Specifically, this approach avoids violation of the orbital septum, which may lead to less eyelid malposition postoperatively. This technique is useful in the younger patient with isolated fat excess who does not need skin excision, as well as in the older patient with manifestations of mild-to-moderate skin redundancy. This approach can be used for lower lid fat removal, fat redraping and redistribution, and as an access point to the midface.¹

History of the Procedure

This technique has been practiced in Europe for nearly 70 years. The first description by Bourget in 1928⁵ was followed by the account of Tessier in 1973⁶ of this approach for blepharoplasty, trauma, and congenital deformities. Isolated reports of this technique for blepharoplasty began appearing in the North American literature during the 1970s⁷ and 1980s⁸, but the landmark contribution by Zarem and Resnick in 1991⁹ propelled this procedure into more widespread acceptance.

Although earlier studies focused on the young patient with isolated fat excess, indications for the procedure may be expanded to include older patients with some degree of cutaneous redundancy. Many studies now report excellent results and a reduced incidence of postoperative lower lid complications. As more experience with this technique is shared and results reviewed, reports have shown fewer complications and less apparent morbidity than with the transcutaneous approach.

Presentation

Preoperative evaluation

Preoperative evaluation includes a thorough history and physical examination. Careful attention to medical history regarding presence of hypertension, current medications, history of bleeding diathesis, and history of dry eyes or eye surgeries. The physical examination must be performed in a complete and sequential manner to assess periorbital anatomy. Eyelids are evaluated for shape and function. In addition, the eyebrows should be evaluated for ptosis and symmetry.¹ Visual acuity as well as field of vision should be evaluated in all patients. Any evidence of herniated fat pads as well as the degree of skin laxity of the lower lid should be noted. As several authors have observed, fat pad herniation is best tested with the patient's eyes in an upward gaze.¹⁰

The finding of scleral show on preoperative evaluation can be caused by a prominent eye, excess lower lid laxity, and poor infraorbital support. Lower lid tone should be assessed via the lower lid "snap back" test in all patients. In this test, the central lower lid is pulled gently away from the eye and is then observed as it returns to its normal resting position. These findings often require lateral canthopexy, wedge excision of redundant tissue, possible midface lift, or orbital rim augmentation.¹

A: The lower eyelid is evaluated for the presence or absence of adequate tone. The snap test is shown. This involves pulling the lower eyelid skin away from the globe with the thumb and index fingers. B: This photograph demonstrates the lid retraction test, which involves displacing the lower eyelid inferiorly in order to evaluate lower eyelid tone. C: This is a preoperative oblique view. Note the brow position in relation to the orbital rim. Note also the excessive eyelid skin and crow's feet in this particular patient. D: Preoperative frontal view of the same patient. Note the lower position of the left brow, the redundancy and asymmetry of the upper eyelid skin, and the crow's feet in the lateral orbital areas.

Patients should also be evaluated for the presence of Bell phenomenon, as patients with poor response may have increased postoperative corneal dryness. These patients and any patient with a history of dry eyes require preoperative tear film evaluation, including a Schirmer test. The Schirmer test uses paper strips inserted into the eye for several minutes to measure the production of tears.¹

Indications

Transconjunctival blepharoplasty has been recognized as useful in patients with fat excess and fine skin wrinkling and in those with apparent skin and fat excess in whom fat excision alone allows for redraping of the lower lid skin into an acceptable contour with elimination of the skin laxity. Although initial reports focused on the young patient with isolated fat herniation, the indications have been broadened somewhat to include patients with modest skin laxity.⁹ Furthermore, the transconjunctival lower blepharoplasty has been shown to be safe and effective along with resecting a pinch of excessive skin to address skin laxity.⁴

Lower lid blepharoplasty (transcutaneous or transconjunctival) is not meant to address fine skin wrinkling. This issue may be better addressed with either chemical peels or laser/mechanical resurfacing.

Relevant Anatomy

Inferior periorbital fat is contained posteriorly by the capsulopalpebral fascia and overlying conjunctiva of the posterior fornix.

Surgical anatomy of upper and lower eyelids.

The capsulopalpebral fascia fuses superiorly with the inferior tarsal muscle, which inserts into the lower border of the tarsal plate. Anteriorly, the fat is bounded by the orbital septum, which separates it from the overlying orbicularis oculi muscle and lower lid skin. With age, these tissues may relax, and the orbital fat may herniate forward, which presents as unnatural fullness of the lower lid. This bulging of the lower lid can also cause a hollowed look of the upper lid, as the entire orbital contents drop.

Transconjunctival blepharoplasty permits access to the orbital fat by an incision through the inferior conjunctiva and capsulopalpebral fascia without any disruption of the skin and orbicularis muscle of the lower lid. This approach avoids violating the inferior orbital septum, which may result in less postoperative eyelid retraction, scleral show, and changes in the shape of the aperture, which may complicate the transcutaneous approach.

The inferior oblique muscle is an important anatomic landmark. It arises from the anteromedial portion of the orbital floor and passes posterolaterally, separating the medial and central fat compartments during its course. The lateral and central fat compartments are separated by the arcuate expansion of the inferior oblique muscle. This diaphanous structure inserts into the orbital rim anterolaterally.

The upper lid classically is divided into an anterior (skin and orbicularis) and a posterior (tarsus and conjunctiva) lamella. The supratarsal fold results from a fusion of levator aponeurosis, orbital septum, and fascia on the deep surface of the orbicularis muscle. The fused layer acts as a sling for the periorbital fat and is higher medially than laterally. In an attempt to divide the orbital septum medially in a conventional blepharoplasty, this fused layer may be damaged inadvertently.

Generally, the presence of either 2 or 3 upper lid fat pads is accepted.¹¹ The medial fat pad is typically pale yellow or white and lies medial to the levator aponeurosis at the root of the nose. It has a greater connective tissue component and is innervated by the supratrochlear nerve. The middle and lateral fat pads lie on the levator and are a rich butter yellow color. They are innervated by the supraorbital nerve.

Contraindications

Dry eye exposure is a risk of any surgical manipulation of the upper or lower lids. Patients who have undergone corrective vision procedures such as laser in situ keratomileusis (LASIK) or keratotomy have an increased risk of dry eye problems and should be cleared for further surgery by their refractive eye surgeon.

Patients wearing contact lenses pose a particular risk when blepharoplasty is considered. Eyes may dry out as a patient ages, and this process is often hastened by chronic contact lens use. Additionally, eyelid surgery such as blepharoplasty, canthopexy, or other lid altering procedures may subtly affect the curvature of the cornea, making use of contact lenses uncomfortable or even dangerous. Patients should discontinue the use of contact lenses weeks before surgery and not restart use for several weeks postoperatively to allow healing without any eyelid manipulation.

Treatment

Intraoperative Details

Transconjunctival blepharoplasty is easily performed with local or general anesthesia. When performed as an isolated procedure, local anesthesia is often preferred with or without intravenous sedation. This can be performed in an office operating room setting.
The conjunctiva and cornea are anesthetized with 2 drops of 0.5% tetracaine hydrochloride ophthalmic solution instilled into the lower fornix of each eye. This is followed with a transconjunctival injection of local anesthetic solution (consisting of 0.5% lidocaine with 1:200,000 epinephrine containing 150 U hyaluronidase additive) into the lower fornix using a 30-gauge needle. To limit patient discomfort during fat excision, the fat pads should be individually anesthetized, as they are exposed during the dissection.
Many surgeons routinely use corneal protectors. However, stay sutures placed through the medial and lateral conjunctival surfaces of the inferior fornix may be used to retract the inferior conjunctiva superiorly, which protects the cornea and gives wide access to the orbital fat once an incision is made. A small double skin hook or traction suture in the lower lid margin exposes the inferior fornix maximally for safe dissection.
One or two incisions in the lower lid conjunctiva are made at least 4 mm below the tarsus, using a Colorado tip monopolar cautery or radiofrequency device. When 2 incisions are made, they should overlap, allowing the preservation of a conjunctival bridge over the inferior oblique muscle in an effort to safeguard this muscle during dissection. The muscle often is visualized clearly in the depths of the wound. Pechter has recently suggested that 3 separate incisions be made to address each of the 3 fat compartments.¹²
Once the orbital fat compartments are entered, gentle pressure on the globe provides a guide to the level of fat resection. Avoiding overresection is important. The quantity of fat resection is more difficult to assess via the transconjunctival approach than with the transcutaneous technique. In the latter approach, the orbital rim provides a useful guide in evaluating the amount of fat to resect; with the transconjunctival approach, this anatomic landmark is not seen as easily.
Hemostasis is assured at the vascular pedicle of each fat pad, with either Colorado tip unipolar cautery or bipolar cautery. The residual fat is returned to its anatomic location, and the conjunctiva is allowed to redrape naturally. No sutures are required to close the inferior conjunctival incisions.

Postoperative Details

The patient should keep his or her upper body and head elevated for several days, especially when sleeping, to reduce swelling and bruising around the eye. A gentle compressive bandage is applied to the lower lid postoperatively to keep the lower lid suspended and provide pressure to the lower lid while healing. This should remain in place until inflammation of the lower conjunctiva has disappeared, typically 3-5 days.

The intermittent application of cold compresses (eg, iced saline solution–soaked dressings) to the eyes postoperatively assists with reduction of bruising and swelling. When the patient is at home, cold compresses can be continued for the next 24-48 hours. Artificial tears or gel may be used at night to ease ocular discomfort.

Complications

The possibility of complications with any surgical procedure should be thoroughly discussed with the patient prior to surgery when obtaining informed consent. Common complications include swelling, ecchymosis, chemosis, and lagophthalmos.

Retrobulbar hemorrhage is a serious complication that results from uncontrolled bleeding within the orbital fat compartment. This results in severe eye pain of sudden onset and can result in bulging of the eye out of the orbit and a decrease in vision. Any severe eye pain in the postoperative period needs to be evaluated emergently, and the patient's head and upper body should be elevated and blood pressure controlled. The bleeding may have to be controlled operatively, with the blood evacuated and bleeding stopped. This may require hospitalization for surgery and medication administration for swelling and blood pressure control. For more information, see eMedicine article Lateral Orbital Canthotomy.

The patient’s face may appear asymmetric postoperatively, which may be due to swelling, bruising, or excess fluid in the tissues around the eye. This may take several weeks to resolve. Surgeons and patients should wait a minimum of 2 months for resolution to occur before making any decision to undergo further corrective surgery.

Chemosis, or inflammation of the conjunctiva, is a rare but aggravating complication of any surgery around the eyelid, especially the lower lid. Treatment is conservative, with the use of lubricating eye drops or ointment. Patients may be given a prescription for steroid medication to reduce the inflammation. If chemosis occurs, any further irritation (eg, allergic irritants, contact lenses) to the conjunctiva should be minimized.

Changes in the shape of the eye aperture, increased scleral show, and changes in the position of the lower lid may still occur; however, these complications have been reported to be reduced with the transconjunctival technique.^13,14,12,4

Future and Controversies

Several reports of transconjunctival approach to lower lid blepharoplasty attest to its efficacy and safety when performed in carefully selected patients. Although some authors have not demonstrated different complication rates between this and the transcutaneous approach, several recent reports and novel modifications of the technique indicate fewer complications from the transconjunctival blepharoplasty provided patients are selected appropriately. Baylis and colleagues in 1989 reported that this approach certainly has reduced the number of cases of lower lid retraction following lower lid blepharoplasty and has minimized dry eye exposure complications.⁸ In addition, this approach produces no external lower lid scarring.

Patient selection remains an important factor. Good candidates are patients with no excess skin or muscle, while poor candidates have significant skin excess, lid laxity, and muscle redundancy. Patients with lid laxity require lid tightening using other techniques. The transconjunctival approach also is useful for correcting isolated medial fat pad herniation in the upper lid or for revisionary procedures in the lower lids when inadequate fat resection has been performed during a previous blepharoplasty.

Multimedia

Media file 1: Surgical anatomy of upper and lower eyelids.

Media file 2:

Media file 3:

Media file 4: A: The lower eyelid is evaluated for the presence or absence of adequate tone. The snap test is shown. This involves pulling the lower eyelid skin away from the globe with the thumb and index fingers. B: This photograph demonstrates the lid retraction test, which involves displacing the lower eyelid inferiorly in order to evaluate lower eyelid tone. C: This is a preoperative oblique view. Note the brow position in relation to the orbital rim. Note also the excessive eyelid skin and crow's feet in this particular patient. D: Preoperative frontal view of the same patient. Note the lower position of the left brow, the redundancy and asymmetry of the upper eyelid skin, and the crow's feet in the lateral orbital areas.

References

Nahai F. Transconjunctival blepharoplasty. In: Nahai F. The Art of Aesthetic Surgery: Principles and Techniques. St. Louis, Missouri: Quality Medical Publishing, Inc.; 2005:Chap 22, pp. 720-50.
Silkiss RZ, Carroll RP. Transconjunctival surgery. Ophthalmic Surg. Apr 1992;23(4):288-91. [Medline].
Zarem HA, Resnick JI. Minimizing deformity in lower blepharoplasty. The transconjunctival approach. Clin Plast Surg. Apr 1993;20(2):317-21. [Medline].
Taban M, Taban M, Perry JD. Lower eyelid position after transconjunctival lower blepharoplasty with versus without a skin pinch. Ophthal Plast Reconstr Surg. Jan-Feb 2008;24(1):7-9. [Medline].
Bourget J. Notre traitement chirurgical de "poches" sous les yeux sans cicatrice. Arch Gr Belg Chir. 31;133:1928.
Tessier P. The conjunctival approach to the orbital floor and maxilla in congenital malformation and trauma. J Maxillofac Surg. Mar 1973;1(1):3-8. [Medline].
Tomlinson FB, Hovey LM. Transconjunctival lower lid blepharoplasty for removal of fat. Plast Reconstr Surg. Sep 1975;56(3):314-8. [Medline].
Baylis HI, Long JA, Groth MJ. Transconjunctival lower eyelid blepharoplasty. Technique and complications. Ophthalmology. Jul 1989;96(7):1027-32. [Medline].
Zarem HA, Resnick JI. Expanded applications for transconjunctival lower lid blepharoplasty. Plast Reconstr Surg. Aug 1991;88(2):215-20; discussion 221. [Medline].
Soll SM, Lisman RD, Charles NC, Palu RN. Pyogenic granuloma after transconjunctival blepharoplasty: a case report. Ophthal Plast Reconstr Surg. Dec 1993;9(4):298-301. [Medline].
Januszkiewicz JS, Nahai F. Transconjunctival upper blepharoplasty. Plast Reconstr Surg. Mar 1999;103(3):1015-8; discussion 1019. [Medline].
Pechter EA. Transconjunctival lower blepharoplasty through interrupted incisions. Plast Reconstr Surg. Jul 2009;124(1):166e-7e. [Medline].
Mohadjer Y, Holds JB. Cosmetic lower eyelid blepharoplasty with fat repositioning via intra-SOOF dissection: surgical technique and initial outcomes. Ophthal Plast Reconstr Surg. Nov-Dec 2006;22(6):409-13. [Medline].
Sadove RC. Transconjunctival septal suture repair for lower lid blepharoplasty. Plast Reconstr Surg. Aug 2007;120(2):521-9. [Medline].
Flowers RS. Upper blepharoplasty by eyelid invagination. Anchor blepharoplasty. Clin Plast Surg. Apr 1993;20(2):193-207. [Medline].

Keywords

transconjunctival blepharoplasty, blepharoplasty, lower lid transconjunctival, transcutaneous blepharoplasty, lower lid malpositions, fat herniation, isolated fat herniation, orbital fat, inferior fornical conjunctiva, capsulopalpebral fascia, ectropion, round eye

Contributor Information and Disclosures

Author

Christian N Kirman, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center
Christian N Kirman, MD is a member of the following medical societies: North Carolina Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Gaurav Bharti, MD, Resident Physician, Department of Plastic and Reconstructive Surgery, Wake Forest University Baptist Medical Center
Gaurav Bharti, MD is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, and Phi Kappa Phi
Disclosure: Nothing to disclose.

Joseph A Molnar, MD, PhD, FACS, Associate Director of Burn Unit, Associate Professor, Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine
Joseph A Molnar, MD, PhD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Parenteral and Enteral Nutrition, American Society of Plastic Surgeons, North Carolina Medical Society, Peripheral Nerve Society, and Wound Healing Society
Disclosure: KCI, Inc. Honoraria Speaking and teaching; Integra Life Sciences Honoraria Speaking and teaching; Clincal Cell Culture Grant/research funds Co-investigator; KCI, Inc Wake Forest University receives royalties Other

Medical Editor

Neal R Reisman, MD, JD, Chief of Plastic Surgery, St Luke's Episcopal Hospital; Clinical Professor of Plastic Surgery, Baylor College of Medicine
Neal R Reisman, MD, JD is a member of the following medical societies: American Association of Plastic Surgeons, American College of Surgeons, American Society for Aesthetic Plastic Surgery, American Society of Plastic Surgeons, Lipoplasty Society of North America, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Lars M Vistnes, MD, FRCSC, FACS, Professor of Surgery, Emeritus, Stanford University Medical Center
Lars M Vistnes, MD, FRCSC, FACS is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors D Glynn Bolitho, MD, PhD, FACS, FRCSC, FCS(SA), and Foad Nahai, MD, to the development and writing of this article.

Further Reading